Review of Related Literature

According to the World Health Organization (WHO), pneumonia is an acute respiratory

infection in which viruses, bacteria, or fungi affect the lungs. It is characterized by fast breathing,
lower chest indrawing, flaring of the nostrils, grunting, and sometimes wheezing. In 2015 alone,
WHO accounted 920,136 pneumonia-related deaths for children aged 5 years and below. The
recorded data corresponds to 16% of all deaths of children, a statistic higher than that of AIDS,
malaria, and measles combined. With a mortality rate of 23.4 per 100,000 people, the Philippines
is among the 15 countries that make up 75% of the world’s childhood pneumonia cases.

Research Institute for Tropical Medicine (RITM) Director and Acute Respiratory
Infection (ARI) Research Group member Dr. Socorro P. Lupisan also confirmed that although
“not many are aware, [but] pneumonia is the number one killer of children. It remains to be one
of the top five causes of deaths among children, worldwide and also here in the Philippines.”
With the thrust to control childhood pneumonia in the country, the RITM-ARI Research Group
through its Science and Technology Research Partnership for Sustainable Development
(SATREPS) project conducted studies to evaluate strategies on effective management measures
to reduce the mortality and prevent pneumonia.

Based on the recommendations of the ARI Research Group studies, pneumonia can be
prevented by reinforcing appropriate health-seeking behaviors, improving healthcare practice
and access, and strategizing health immunization programs. Manalo admitted that she was
administering medications for Julian without the proper prescription from a doctor. With the
hopes of improving Julian’s condition, the self-prescribed medications actually made Julian’s
condition worse. “Akala ko kasi talaga normal na ubo’t sipon lang siya, kaya pinainom ko siya
ng mga gamot na para sa ubo’t sipon. Pero nung sobrang taas na ng lagnat niya, at di na kaya
pababain nung gamot, dun na namin siya dineretso sa ospital (At first, I really thought it was just
the common cold and cough, so I gave Julian over-the-counter medications. However, when his
fever got really high and the medications weren’t helping, that was when we rushed him to the
nearest hospital),” said Manalo. When asked if she noticed any probable symptom of pneumonia,
Manalo mentioned fast breathing. However, since was not aware of pneumonia, Manalo quickly
associated the fast breathing to asthma which Julian has. The gap in the knowledge level and
health-seeking behavior of mothers is one of the greatest obstacles in eliminating childhood
pneumonia in the Philippines.
 Former ARI Research Group Head and the immediate Past President of the Pediatric
Infectious Disease Society of the Philippines Dr. Salvacion Gatchalian explained that “there is
increased mortality in pneumonia, because children are only brought to the hospital when it’s
already too late. It is because some people do not know, they do not realize the gravity of the
situation.” Socio-economic status played a role as well in hindering Manalo to seek professional
advice when her son felt ill. “Naisip ko kasi na yung gagastusin ko para maipacheck up si Julian,
pwede ko na rin magamit na pambili niya ng gamot (I thought to myself that the money I would
spend to get Julian checked could also be the money I can use to buy his medicines),” said
Manalo. Still, Dr. Gatchalian urges parents to bring in patients early since health care centers and
public hospitals offer free consultation.

“Pneumonia is preventable. It is actually the late consult that increases the risk for
mortality and morbity,” Dr. Gatchalian emphasized. Striving to improve healthcare. One of the
co-investigators of the SATREPS project from Tohoku University Dr. Mariko Saito-Obata shared
that lower socioeconomic status, and maternal reasons were major risk factors. She also
mentioned that cost distance was slightly associated to an increased incidence of pneumonia.

A significant update on the etiology of childhood pneumonia in the Philippines was found
as well. On a national level, the scientists from Japan and the Philippines through the RITM-ARI
SATREPS project managed to disprove the long-held belief that pneumonia is largely caused by
bacteria. The group found that viruses were more common etiologic agents of childhood
pneumonia with the respiratory syncytial virus (RSV) as the most common cause. “RSV was the
most common pathogen observed in children with pneumonia. It was not causing significant
mortality compared to other viruses, but it was causing illnesses and admissions to hospitals,”
explained Dr. Lupisan.

She then added that the group is currently studying the transmission of RSV and hopes to
come up with a recommendation for control – “an RSV vaccine maybe, so we can decrease
hospital admissions of children,” said Dr. Lupisan. Health professionals continue to play an
important and critical role in the control of pneumonia in the country, as Dr. Gatchalian cited.
She stated that health professionals need to constantly be aware of the early symptoms of
pneumonia, particularly fast breathing. But more importantly, she emphasized that doctors
should use drugs rationally and appropriately to avoid the development of antibiotic resistance.
 “The rising antibiotic resistance is the challenge to treatment these days, even among
adults,” Dr. Gatchalian underscored. Vaccination saves you all the trouble Dr. Gatchalian
mentioned that non-immunization is one of the definite risk factors that makes any child more
vulnerable to pneumonia, so she highlighted that this should really be taken into consideration.

In 2013, the Department of Health introduced the Pneumococcal Conjugate Vaccine

(PCV) as an addition to its free basic immunization program for children in the health centers
across the country. The RITM-ARI Research Group conducted trials that assessed the efficacy of
PCV and found that areas within the country with poor access to healthcare have the highest
vaccine efficacy (Lupisan, 2013). Thus, the group recommended an alternative strategy to
universal vaccination which is to target vaccination to areas where children are most likely to
benefit. “High mortality in pneumonia is not just because of the socioeconomic status,” noted Dr.
Gatchalian as she cited that local health strategies are in place to reduce the number of child
deaths linked to pneumonia. On the other hand, Dr. Gatchalian also mentioned that risk factors
for pneumonia is really a “spectrum of everything”.

She pointed out that “there should be increased immunization coverage, and most
importantly health education for mothers and health care providers, so that patients can be
treated as early as possible.” As for the case of Manalo, it was all lessons learned for her and her
son’s experience in battling and surviving the dreaded pneumonia. Ever since Julian’s recovery,
Manalo made it a point to keep her son’s health in tiptop shape. “Dapat pala huwag na nating
hintayin lumala ang nararamdaman ng mga anak natin, bago tayo magpatingin at makinig sa mga
payo ng mga doktor (We should not wait for our children’s illness to worsen, before we visit
doctors and follow their instructions),” Manalo ended.

Meanwhile, the RITM-ARI and SATREPS partnership was nothing short of fruitful for
both Japan and the Philippines. Various technologies were introduced to the Philippines,
including the use of the pulse oximeter that helped diagnose and categorize pneumonia. Data
collected in the project sites also gave way for a plethora of research papers to be published by
Japanese and Filipino researchers. While the project has already been concluded last year, clearly
the hope to see the prevention and control of the disease that inflicts death on many Filipino
children is still very much alive.
What should do first?

Control your fever with aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs, such as
ibuprofen or naproxen), or acetaminophen. DO NOT give aspirin to children. QDrink plenty of
fluids to help loosen secretions and bring up phlegm. Do not take cough medicines without first
talking to your doctor. Coughing is one way your body works to get rid of an infection. If your
cough is preventing you from getting the rest you need, ask your doctor about steps you can take
to get relief. Drink warm beverages, take steamy baths and use a humidifier to help open your
airways and ease your breathing. Contact your doctor right away if your breathing gets worse
instead of better over time. Stay away from smoke to let your lungs heal. This includes smoking,
secondhand smoke and wood smoke. Talk to your doctor if you are a smoker and are having
trouble staying smokefree while you recover. This would be a good time to think about quitting
for good. Get lots of rest. You may need to stay in bed for a while. Get as much help as you can
with meal preparation and household chores until you are feeling stronger. It is important not to
overdo daily activities until you are fully recovered.(Ad·www.lung-health.org/2020Lung Health,
Prague 2020 | International Workshop | lung-health.org)

Classification and type of pneumonia

The most common causes of CAP vary depending on a person's age, but they include
Streptococcus pneumoniae, viruses, the atypical bacteria, and Haemophilus influenzae. Overall,
Streptococcus pneumoniae is the most common cause of community-acquired pneumonia
worldwide. Lobar pneumonia usually has an acute progression. Classically, the disease has four
stages: Congestion in the first 24 hours: This stage is characterized histologically by vascular
engorgement, intra-alveolar fluid, small numbers of neutrophils, often numerous bacteria.
Grossly, the lung is heavy and hyperemic.(Classification of pneumonia - Wikipedia). There are
more than 30 different causes of pneumonia, and they’re grouped by the cause. The main types
of pneumonia are: Bacterial pneumonia. This type is caused by various bacteria. The most
common is Streptococcus pneumoniae. It usually occurs when the body is weakened in some
way, such as by illness, poor nutrition, old age, or impaired immunity, and the bacteria are able to
work their way into the lungs. Bacterial pneumonia can affect all ages, but you are at greater risk
if you abuse alcohol, smoke cigarettes, are debilitated, have recently had surgery, have a
respiratory disease or viral infection, or have a weakened immune system. Viral pneumonia. This
type is caused by various viruses, including the flu (influenza), and is responsible for about one-
third of all pneumonia cases. You may be more likely to get bacterial pneumonia if you have
viral pneumonia. Mycoplasma pneumonia. This type has somewhat different symptoms and
physical signs and is referred to as atypical pneumonia. It is caused by the bacterium
Mycoplasma pneumoniae. It generally causes a mild, widespread pneumonia that affects all age
groups. Other pneumonias. There are other less common pneumonias that may be caused by
other infections including fungi.(Pneumonia | Johns Hopkins Medicine)

Signs and Symptoms

the following signs and symptoms:

 Have a high fever

 Have shaking chills

 Have a cough with phlegm (a slimy substance), which doesn't improve or worsens

 Develop shortness of breath with normal daily activities

 Have chest pain when you breathe or cough

 Feel suddenly worse after a cold or the flu

If you have pneumonia, you also may have other symptoms, including nausea (feeling sick to
the stomach), vomiting, and diarrhea. Symptoms may vary in certain populations. Newborns and
infants may not show any signs of the infection. Or, they may vomit, have a fever and cough, or
appear restless, sick, or tired and without energy. Older adults and people who have serious
illnesses or weak immune systems may have fewer and milder symptoms. They may even have a
lower than normal temperature. If they already have a lung disease, it may get worse. Older
adults who have pneumonia sometimes have sudden changes in mental awareness.(Pneumonia |
National Heart, Lung, and Blood Institute (NHLBI))

Risk Factors

 Risk factors that increase a child's chance of getting CAP include:

 Being younger than 6 months of age
 Being born prematurely
 Birth defects, such as cleft palate
 Nervous system problems, such as seizures or cerebral palsy
 Heart or lung disease present at birth
  Weak immune system (this can occur due to cancer treatment or disease such as
HIV/AIDS)
 Recent surgery or trauma(https://medlineplus.gov/ency/article/007690.htm)

Complications

Often, people who have pneumonia can be successfully treated and do not have
complications. Possible complications of pneumonia may include:

Bacteremia and septic shock. Bacteremia is a serious complication in which bacteria from
the initial site of infection spread into the blood. It may lead to septic shock, a potentially fatal
complication. Lung abscesses. Lung abscesses usually are treated with antibiotics. Sometimes
surgery or drainage with a needle is needed to remove the pus. Pleural effusions, empyema, and
pleurisy. These painful or even potentially fatal complications can occur if pneumonia is not
treated. The pleura is a membrane that consists of two large, thin layers of tissue. One layer
wraps around the outside of your lungs and the other layer lines the inside of your chest cavity.
Pleurisy is when the two layers of the pleura become irritated and inflamed, causing sharp pain
each time you breathe in. The pleural space is a very thin space between the two pleura. Pleural
effusions are the build-up of fluid in the pleural space. If the fluid becomes infected, it is called
empyema. If this happens, you may need to have the fluid drained through a chest tube or
removed with surgery. Renal failure. Respiratory failure.(Pneumonia | National Heart, Lung, and
Blood Institute (NHLBI))

Prognosis

Most people with pneumonia improve after three to five days of antibiotic treatment, but
a mild cough and fatigue can last longer, up to a month. Patients who required treatment in a
hospital may take longer to see improvement. Pneumonia can also be fatal. The mortality (death)
rate is up to 30% for patients with severe pneumonia who require treatment in an intensive care
unit. Overall, around 5%-10% of patients who are treated in a hospital setting die from the
disease. Pneumonia is more likely to be fatal in the elderly or those with chronic medical
conditions or a weakened immune system.(Pneumonia Symptoms, 4 Stages, Causes, and Cure -
MedicineNet)

Prevention
 Check with your healthcare provider about getting immunizations. The flu is a common
cause of pneumonia. Because of that, getting a flu shot every year can help prevent both the flu
and pneumonia. There is also a pneumococcal vaccine. It will protect you from a common form
of bacterial pneumonia. Children younger than age 5 and adults ages 65 and older should get this
shot. The pneumococcal shot is also recommended for all children and adults who are at
increased risk of pneumococcal disease due to other health conditions.(Pneumonia | Johns
Hopkins Medicine).

Test and Diagnosis

Diagnosis is usually made based on your recent health history (such as surgery, a cold, or
travel exposures) and the extent of the illness. Based on these factors, your healthcare provider
may diagnose pneumonia simply on a thorough history and physical exam. The following tests
may be used to confirm the diagnosis:

 Chest X-ray. This test takes pictures of internal tissues, bones, and organs, including the
lungs.

 Blood tests. This test may be used to see whether infection is present and if infection has
spread to the bloodstream (blood cultures). Arterial blood gas testing checks the amount
of oxygen in your bloodstream.

 Sputum culture. This test is done on the material that is coughed up from the lungs and
into the mouth. It’s often used to see if there’s an infection in the lungs.

 Pulse oximetry. An oximeter is a small machine that measures the amount of oxygen in
the blood. A small sensor is taped or clipped onto a finger. When the machine is on, a
small red light can be seen in the sensor. The test is painless and the red light does not get
hot.

 Chest CT scan. This imaging procedure uses a combination of X-rays and computer
technology to produce sharp, detailed horizontal, or axial, images (often called slices) of
the body. A CT scan shows detailed images of any part of the body, including the bones,
muscles, fat, and organs. CT scans are more detailed than regular X-rays.
  Bronchoscopy. This is direct exam of the bronchi (the main airways of the lungs) using a
flexible tube (called a bronchoscope). It helps to evaluate and diagnose lung problems,
assess blockages, and take out samples of tissue and/or fluid for testing,

 Pleural fluid culture. In this test, a sample of a fluid sample is taken from the pleural
space. This is the space between the lungs and chest wall. A long, thin needle is put
through the skin between the ribs and into the pleural space. Fluid is pulled into a syringe
attached to the needle. It is sent to the lab where it’s tested to find out which bacteria is
causing the pneumonia.(Pneumonia | Johns Hopkins Medicine)

Culture

Bronchopneumonias are the most common infections producing diffuse coalescent

opacities. Gram-negative organisms are particularly notorious for producing such fulminant
pneumonias. This pattern is frequently preceded by radiographs showing multifocal ill-defined
opacities like those described in Chapter 16. There is a tendency for the patient to have some
volume loss because of the bronchial inflammation. The loss of volume may cause one lobe to
appear predominantly involved during the course of the illness. In some cases, the radiologic
patterns of bronchopneumonia and pulmonary edema are identical, but an asymmetric, patchy, or
even unilateral presentation is more consistent with the diagnosis of bronchopneumonia. It must
be remembered that pulmonary edema may also produce a patchy or asymmetric distribution
when there is underlying disease such as emphysema or pulmonary embolism. Clinical and
laboratory data may be useful in distinguishing bronchopneumonia from pulmonary edema.
Bronchopneumonia should result in a febrile response with productive purulent sputum and
leukocytosis. Culture of sputum and blood usually confirms the diagnosis and identifies the
organisms(https://www.sciencedirect.comBronchopneumonia - anoverview|ScienceDirectTopics)

Medication/treatment

Treatment for bronchopneumonia may depend on the type of infection and the severity of
the condition. People without other health problems typically recover from bronchopneumonia
within 1 to 3 weeks. It is possible to treat mild forms of bronchopneumonia at home using a
combination of rest and medication. But, more severe cases of bronchopneumonia may require
hospital treatment. Doctors treat people whose bronchopneumonia is due to a bacterial infection
with antibiotics. These drugs work by killing harmful bacteria in the lungs. When taking
antibiotics, it is essential to carefully follow the doctor's instructions and complete the full course
of medication. Antibiotics do not work for viral infections.

For viral bronchopneumonia, a doctor may prescribe an antiviral medication for people
with the flu, or they may direct therapy at treating symptoms. Bronchopneumonia due to a virus
typically clears up in 1 to 3 weeksTrusted Source. For people with fungal bronchopneumonia, a
doctor may prescribe antifungal medication. When recovering from bronchopneumonia, it is
essential for a person to: 1 get plenty of rest drink lots of fluids to help thin mucus and reduce
discomfort when coughing take all medications, as their doctor directs.

Prevalence

Pneumonia and other lower respiratory tract infections are the leading cause of death
worldwide. The WHO Child Health Epidemiology Reference Group estimated the median global
incidence of clinical pneumonia to be 0.28 episodes per child-year. This equates to an annual
incidence of 150.7 million new cases, of which 11-20 million (7-13%) are severe enough to
require hospital admission. Ninety-five percent of all episodes of clinical pneumonia in young
children worldwide occur in developing countries. Approximately 150 million new cases of
pneumonia occur annually among children younger than 5 years worldwide, accounting for
approximately 10-20 million hospitalizations. A WHO Child Health Epidemiology Reference
Group publication cited the incidence of community-acquired pneumonia among children
younger than 5 years in developed countries as approximately 0.026 episodes per child-year, and
a study conducted in the United Kingdom showed that 59% of deaths from pertussis are
associated with pneumonia. In 2015 alone, WHO accounted 920,136 pneumonia-related deaths
for children aged 5 years and below. The recorded data corresponds to 16% of all deaths of
children, a statistic higher than that of AIDS, malaria, and measles combined. With a mortality
rate of 23.4 per 100,000 people, the Philippines is among the 15 countries that make up 75% of
the world’s childhood pneumonia cases.

Epidemiology

In the Philippines, 57,809 pneumonia deaths were reported in 2016, nearly 10 percent of
582,183 registered deaths in 2016. This made pneumonia the 3rd top killer behind ischemic
heart disease and cancer. The most common symptoms of pneumonia are: Cough (with some
pneumonias you may cough up greenish or yellow mucus, or even bloody mucus), fever, which
may be mild or high (as high as 105 degrees F), shaking and chills and shortness of breath, which
may only occur when you climb stairs. You may also experience sharp or stabbing chest pain that
gets worse when you breathe deeply or cough, headache, eExcessive sweating and clammy skin,
loss of appetite, low energy, and fatigue and confusion, especially in older people. A number of
things can cause pneumonia to include bacteria, viruses and other infectious agents. Risk factors
for pneumonia include age younger than 5 and older than 65, cigarette smoking and recent viral
respiratory infection a cold, laryngitis, influenza, etc. This is why physician Denky Shoji dela
Rosa said, “It is important to emphasize that there are vaccinations, the flu vaccine which is
given every year, pneumonia vaccines so adults would decrease their likelihood of contracting
the infection. Other infectious diseases making the top 10 causes of death in the Philippines
include tuberculosis #8 with 24,462 cases and chronic lower respiratory infections #9 with 24,
236 cases.

Etiology

Pneumonia is a lung disease characterized by inflammation of the airspaces in the lungs,

most commonly due to an infection. Pneumonia may be caused by viral infections, bacterial
infections, or fungi; less frequently by other causes. The most common bacterial type that causes
pneumonia is Streptococcus pneumoniae.